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BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c162 (Published 12 January 2010) Cite this as: BMJ 2010;340:c162

Mefloquine and mental health problems among U.S. military personnel

To reduce the risk of serious adverse events including anxiety, paranoia,
depression, hallucinations, and psychosis, mefloquine is contraindicated
among those with certain prevalent neuropsychiatric disorders. Due in part to
rising rates of mental health disorders among deployed U.S. military
personnel, the prevalence of these contraindications has been previously
shown to be approximately 1 in 10 within this population (Malaria
Journal
doi:10.1186/1475-2875-7-30).

In the summary of my recent research on patterns of mefloquine prescribing
among deployed U.S. military personnel, BMJ erroneously states that
mefloquine was incorrectly prescribed to 1 in 7. In fact, among the 4,505 to
whom mefloquine was prescribed in this study, 155 (3.4%) had documented
contraindications. The correct figure is therefore closer to 1 in 29. However,
among those with documented contraindications, mefloquine was indeed
inappropriately prescribed to 1 in 7.

The U.S. package insert cautions that "[d]uring prophylactic use, if psychiatric
symptoms such as acute anxiety, depression, restlessness or confusion
occur, these may be considered prodromal to a more serious event. In these
cases, the drug must be discontinued". Given that approximately 3.4% of
those prescribed mefloquine in this study had evidence of psychiatric
symptoms even prior to beginning prophylactic use, and may have been
exposed to mefloquine for the duration of combat deployments lasting as
long as 15 months, it is reasonable to conclude that this inappropriate
prescribing may have led to a number of "more serious" events within this
population.

The findings of this research are likely generalizable to other recent U.S.
military deployments, such as those in Somalia, Iraq, and Afghanistan where
mefloquine was widely used. From this, it seems reasonable to conclude that
the inappropriate prescribing of mefloquine to those at risk of serious
adverse events must in some measure be contributory to the current burden
of serious mental health disorders among U.S. military personnel.

Competing interests:
None declared

Competing interests: No competing interests

13 January 2010
Remington L. Nevin
Preventive Medicine Physician
US Army Medical Corps, Silver Spring, MD 20910